Medical-surgical Nursing Demystified

(Sean Pound) #1

CHAPTER 10 Integumentary System^403



  • Oral antibiotics may be necessary.

  • Administer pain medications (oxycodone, morphine) as needed, especially
    before dressing changes that may be painful.

  • Prevent heat loss due to large areas of tissue exposed from lack of skin
    coverage.

  • Maintain fluid levels since fluid loss is common from evaporation and
    wound drainage.


NURSING DIAGNOSES



  • Risk of fluid volume deficit

  • Pain, discomfort

  • Risk of altered body temperature


NURSING INTERVENTION



  • Anticipate pain medication needs to make the patient more comfortable.

  • Assist in range of motion to avoid contracture development due to pain with
    movement.

  • Encourage family visitation.

  • Assist with activities of daily living.

  • Isolation may be needed to protect the patient from bacteria, especially if a
    large amount of skin is not intact.

  • Teach the patient to look for signs and symptoms of infection: fever, increased
    redness, increase in drainage, or change in color of drainage.


Dermatitis


WHAT WENT WRONG?


Inflammation of the skin as a result of contact with an irritating substance such as a
chemical, foreign substance, medication, or contact with a plant, such as poison ivy.
The skin may become reddened, irritated, and itchy. The usual causes are allergic
reactions. Often the patient has a history or a family history of asthma, allergy, or


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